Direct Access Endoscopy

A streamlined process avoiding unecessary delay

* mandatory fields

Does patient meet criteria being less than 70 years of age of reasonable health (without kidney or heart failure)?*

Patient’s Given Name *

Patient’s Last Name *

Patient’s Middle Names

Patient’s Date of Birth (dd/mm/yyyy)*

Patient’s Telephone (Mobile)*

Patient’s Email Address *

Patient’s Residential Address *

Does patient have Medicare?*

Patient’s Medicare Number

Medicare Reference Number (the number in front of your name)

Does patient have private health insurance?*

Patient’s Private Health Insurer

Patient’s Private Health Insurance Membership Number

Is the patient taking blood thinners?

Is the patient taking diabetic medications?

Is the patient taking weight loss medications?

Does the patient have a coronary stent or valve replacement?

Referring Doctor’s first and last name

Referring Doctor’s phone number or practice details

Referring Doctor’s fax number, email or HealthLink EDI

Referring Doctor’s Provider Number

What is the reason for having an endoscopy procedure?*

Procedure required*

Please add any additional comments

Does the patient give permission for one of our staff to call them and organise their booking? *

* Yes, patient consents to being contacted.